Laserfiche WebLink
SERVICE REQUEST CEN 00 61) Revised 9/21/93 <br /> FACILITY IDs RECORD ID N O INVOICE M <br /> FACILITY NAME Dcho�A- BILLING PARTY <br /> SITE ADDRESS <br /> CITY . <br /> OUNERIOPERAYOR ^ S oCMo At— BILLING PARTY <br /> Q/ N <br /> DBA PHONE ai t W()!53:7- <br /> ADDRESS I3waA`,' t-Gry") � /r'}r[� 9 PHONE tl2 < > - <br /> CITY STATE C-111— 21P cl <br /> p ARM • F lard Use Application N <br /> BOS Dist location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR Al(_W BILLING PARTY T <br /> DBA c PHONE s1 W9_) fla <br /> Gafl6 <br /> NAILING ADDRESSC/ v/�.,,1 w��I� FAX � <br /> �s ]tl�?� <br /> CITY L/��i „ ' yam/( STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of sacro, acknowledge that all site and/or project specific <br /> PHS/END hourly chorges associated with this foci lity or activity wi it be billed to the party identified as the BILLING DARTY on <br /> Page 1 of this form. ' <br /> I also certify that I have prepared this apptication and that the Work to be performed will be done in accoffWl SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, state and federal laws. <br /> APPLICANT'S SIGNATURE : �� /JJ��t MAR 161998 <br /> Title: `LC TyQst [J 7' �� fi�2�� SAN JUAQUINLTH SERVICES Date: pSAN J HEALTH COUNTY <br /> ENVIFIONFAENTAL HEALTH DNIBION <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> tnvirm ntal/site assessment inf OTMAlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL NEALTN DIVISION as soon as <br /> it is available and at the same tine it is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to 1 Employee R Dote .3 <br /> Date Service Cooptetad _/ 1 Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check a Recvd By <br /> z3 - b <br /> RENS �/'z/�/ SLAY _/J_ ACCT _/_/�� UNIT CLK /�^ <br />